Thursday, June 27, 2019

Of Surgery and Wounds

Hey guys, here’s a classification of surgical procedures, wounds and their infection risk.

[Please click on the image to enhance it]

Thank you for your time.
- Ashish Singh.

What Is Going On In Fibromyalgia?

Hi there! Let’s talk about pathophysiology of fibromyalgia; a chronic disorder where fatigue and widespread pain feature prominently.

Current hypothesis says, it’s caused by aberrant peripheral and central pain processing.
Two key features are allodynia, that is, pain in response to a non-painful stimulus and hyperaesthesia, which is, exaggerated perception of pain in response to mildly painful stimulus.

Modern research says, certain antidepressants- with both serotonergic and noradrenergic activity- such as TCAs and venlafaxine, can relieve pain and other symptoms; suggesting the pathway involvement.

Some evidence says, alternative therapies such as acupuncture and spa therapies alleviate pain, which have been postulated to act via similar spinal pain-modulatory pathways.

CSF studies show increased levels of substance P, with decreased levels of noradrenaline and serotonin metabolites. All three are neurotransmitters involved in descending pain-modulatory pathways in the spinal cord.

PET images show an abnormal central dopamine response to pain.

The critical question here is: what is cause and what is effect?

Small sample size and short periods of study, remain the most cumbersome challenge to our complete understanding of fibromyalgia.  

Thank you for reading.
- Ashish Singh.

Wednesday, June 26, 2019

Mnemonic: Duke’s Criteria for Infective Endocarditis

Infective endocarditis is diagnosed using the modified Duke’s criteria.
Let’s look at them in an easy-to-remember way.

It’s, quite literally, proving the name Infective Endocarditis to be true.

Infective, that is, positive blood culture:
• Typical bugs in 2 separate cultures
• Persistently positive blood cultures, say > 12h apart
• Single positive blood culture for Coxiella burnetii

Endocarditis, that is, endocardium involvement:
• On imaging with 2D Echo or CT, look for vegetation, abscess, pseudoaneurysm or dehiscence of prosthetic valve
• On clinical exam, find new regurgitation murmur

Remember, patients feel very ill when they have infective endocarditis.
Predisposing factors: congenital heart disease, prosthetic heart valves, iv drug abuse
Fever > 38 °C
Vascular phenomena: emboli, Janeway’s lesions
Immunologic phenomena: glomerulonephritis, Osler’s nodes

What if the blood culture is positive but does not meet the major criteria?
It’s considered as a minor criterion (casually speaking, problematic but not majorly problematic).

How do we use this for diagnosing?
2 major OR
1 major + 3 minor OR
All 5 minor criteria, make up the diagnosis.

Clinical Pearl: Fever with any new-onset murmur is taken as infective endocarditis, unless proven otherwise.

Hope this helps. Happy studying!
- Ashish Singh.

Friday, June 21, 2019

CABG For Undergraduates

CABG is Coronary Artery Bypass Graft; a surgical procedure where dying heart muscle is resupplied with blood.

[decided after a SYNTAX scoring system]
• Left main stem disease
• Triple-vessel disease involving proximal left anterior descending
• Patients unsuitable for angioplasty 
• Failed angioplasty
• Refractory angina

• The heart is usually stopped and blood pumped artificially by a machine outside the body, a cardiac bypass. An alternative, that does not require this, is minimally invasive thoracotomy.
• As the graft, patient’s own great saphenous vein, internal mammary artery or radial artery is used. Multiple grafts may be placed. Arterial grafts last longer but may cause donor site numbness.

After CABG
• Continue aspirin 75 mg/day indefinitely. Consider clopidogrel, if aspirin contraindicated.
• Ensure optimal management of hypertension, diabetes and dyslipidemia.
• Counsel for smoking and alcohol cessation.
• Chart out graded physical activity through rehabilitation.
• Uncommonly, angina may persist or recur [from poor graft run-off, distal disease, new atheroma or graft occlusion]. If so, restart anti-anginal drugs and consider angioplasty.

Clinical Pearl: Recent randomised control trials indicate that early procedural mortality rates and 5-year survival rates are similar after PCI and CABG.

Thank you for reading.
- Ashish Singh.

Understanding Refeeding Syndrome

Refeeding syndrome is a life-threatening metabolic complication of - stay with me - refeeding. It can happen via any route after prolonged starvation.

Who are at risk?
They’re patients with prolonged artifical feeding [parenteral or enteral], malignancy, anorexia and alcoholism.

Why does it happen?
During starvation, the body uses fat and protein for energy. There’s no carbs so there’s little to no insulin.

After refeeding, carbohydrate load causes a spike in insulin level.
Now first prof biochemistry tells you, more insulin means more cellular uptake of phosphate.
That’s it. That low serum phosphate level is the main problem.

How does it present?
Non-specifically and catastrophically. Features are rhabdomyolysis, red and white blood cell dysfunction, respiratory insufficiency, cardiac arrhythmias and seizures.
Left unchecked, it can lead to sudden death.

How do I prevent it?
Identify at-risk patients and give high-dose, high-potency Vitamin C and B complex injection, during re-feeding window.
Monitor vitals and labs closely. Close involvement of nutritionist is ideal.

What if it’s already happened? How do I treat it?
The biggest challenge is management of complications.
As regards phosphate, get the levels back up. Administer oral as well as parenteral phosphate, upto 18 mmol per day.

Thank you, that’d be all.
- Ashish Singh.

What are APS?

APS or Autoimmune Polyendocrine Syndromes are exactly what the name suggests.
They’re autoimmune in origin and they attack more than one endocrine system.

[Please click on the image to enhance it]

Let’s not forget autoimmunity begets autoimmunity.
APS are commonly seen with hypogonadism, vitiligo, alopecia, pernicious anaemia and coeliac disease, among others.

That’d be all. Happy studying!
- Ashish Singh.

Wednesday, June 5, 2019

PR depression in pericarditis

Do you know what P-R segment deviations in acute pericarditis mean?

It is due to subepicardial atrial injury!

Sunday, June 2, 2019

Residency in India: Harassment, abuse and suicide

A few days ago, a resident committed suicide. One of us committed suicide.

In my opinion, it seems like the reason for the suicide was harassment, abuse, and excessive work load. If you ask any resident in any government hospital in Mumbai - they are all treated the same. The verbal abuse is probably different - They used casteist slurs for her. If you are privileged, they will call you different names.

How can we make sure this never happens again? Stop carrying forward the culture of abuse. It is high time. We have to fight the system. The past. The belief that it is okay just because it's residency. Don't look at how our seniors treated us but look at how we treat our juniors.

We need to treat each other better. Treat others how you would like to be treated yourself.

We need to help each other.

It is our fault that the life of an innocent was lost. It's because we didn't fight and we stayed silent when we saw abuse around us. We need to create awareness among medical students that will be joining residency. Let's talk about the abuse and how we can stop it. Residents should know who to report to without fear of negative consequences.

It will take time and it will probably not change in a day. But we are the future and we need to fight.

Fundoscopic images of Diabetic Retinopathy

Fundoscopic images of Diabetic Retinopathy

Images and audio by Sushrut.